Role as a Healthcare Worker

We have important roles* in ensuring the TLD transition is successful

Use

Inventory Management

Prescribing TLD to the eligible patients

Counselling patients regarding the transition

Timely and accurate reporting of stocks and other issues

Product/Supplier selection

Inventory Management* Forecasting

Use* Procurement

Distribution

Reporting through Form BC

HIV CARE REPORT

The Law on Reporting Disease (R.A. 3573) & the Philippine AIDS Prevention and Control Act (R.A. 8504) requires physicians to report all diagnosed HIV infections to the HIV & AIDS Registrar at the Epidemiology Bureau, DOH. Please write in CAPITAL LETTERS and CHECK the appropriate boxes.

BC

VISIT INFO

IF FIRST VISIT

LABORATORY TESTS

TB INFORMATION

OI

OB HIV Confirmatory Code:

Date of visit: (MM / DD / YYYY)

Visit type: ☐ First consult at this facility; trans-in from: ☐ Follow-up ☐ Inpatient

Patient code:

Physician's name: Facility name: (HIV treatment facility) Facility address: Facility contact #:

If this is the patient's first care visit at this facility , please fill out this section:

UIC: __ __ | __ __ | __ __ | __ __ __ __ __ __ __ __ Philhealth No.:

* UIC: First two letters of mother's name, first two letters of father's name, two-digit birth order, birthdate (MM-DD-YYYY)

Patient's full name:

Sex (at birth): ☐ M ☐ F History of PreP: ☐

Current residence: City/Municipality: Province:

KP Class: ☐ MSM ☐ TGP ☐ SW ☐ IDU ☐ Partner of KP Already diagnosed with current active TB by another facility? ☐ Yes ☐ No Already on treatment for current active TB prior to this visit? ☐ Yes ☐ No WHO Classification: ☐ I ☐ II ☐ III ☐ IV

Latest results Date done

Viral load CD4 count Chest X-ray Gene Xpert HIVDR & Genotype

Results

copies/mL Creatinine

cells/µL HBsAg

Date done Results

μmol/L IU/mL

Presence of at least one of the following: weight loss, cough, night sweats, fever? ☐ Yes ☐ No

No active TB With active TB

IPT Status: ☐ Started IPT this visit ☐ Ended IPT this visit Site: ☐ Pulmonary ☐ Extrapulmonary ☐ Ongoing IPT Drug resistance: ☐ Susceptible ☐ MDR ☐ XDR ☐ Not on IPT ☐ RR only ☐ Other:

IPT outcome (if ended IPT this visit): ☐ Completed ☐ ☐ Stopped before target end ☐ Other: TB treatment status: ☐ Ongoing ☐ Completed

☐ Not on tx ☐ Other:

TB tx outcome ☐ Cured ☐ Failed (if ended this visit): ☐ Not yet evaluated ☐ Other:

Infections currently present (check all that apply):

☐ Hepatitis B ☐ Pneumocystis pneumonia (PCP) ☐ Hepatitis C ☐ CMV retinitis Currently taking: ☐ Cotrimoxazole prophylaxis ☐ Azithromycin prophylaxis ☐ Oropharyngeal candidiasis ☐ Others (specify)

Currently pregnant: ☐ No ☐ Yes; Age of gestation: If delivered, date of delivery: Type of infant feeding: ☐ Breastfeeding ☐ Formula feeding ☐ Mixed feeding

ART REGIMEN ART Status:

☐ Enrolling this visit ☐ Continuing ☐ Not on ART

Reason if not on ART:

PHARMACY HACT Physician approval:

Date Dispensed

Drug

Drug

# of pills # pills missed # of pills Date discontinued

per day (past 30 days) left

Reason (D/C code)

Discontinuation codes:

3-Patient Decision/Request 6-Adverse Event (Specify) 1- Treatment Failure 4-Compliance difficulties 7-Others (Specify) 2-Clinical progression/hospitalization 5-Drug Interaction 8-Death

# of pills on hand # of pills dispensed

Dispensed by:

Please send this accomplished form to Epidemiology Bureau - Department of Health, 2/F Rm. 209, Building 19, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila Contact Nos: (02) 310-1452 & (02) 651-7800 loc. 2952 | EB-DOH Form BC (HIV Care Report) v2017

TDF+3TC+DTG